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WELL/PUMP PERMIT <br />e SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 665 W Peltier Rd <br />CITY/ZIP <br />Thornton / 95242 <br />CROSS STREET N. Thornton Rd <br />APN011-120- 1 & 011-130-38 PARCEL SIZE 43.5 <br />LAND USE APPLICATION# <br />OWNER NAME <br />./ Gl/ <br />PHONE <br />G <br />,- /x)0/1 <br />O" 6 <br />y/ ,�1 (�' <br />5 o 4, <br />OWNER ADDRESS 1 U i1 <br />Y) / CITYISTATEIZIP <br />^ � 1 / <br />CONTRACTOR Kleinfelder, Inc. <br />PHONE 209-577-4333 <br />CONTRACTOR ADDRESS 1224 6th Street <br />CITY/STATE/ZIP <br />Modesto / CA/ 95354 <br />SUBCONTRACTOR -Tab&F-&"M- <br />PHONE 0+&474-2244. <br />SUBCONTRACTOR ADDRESS <br />CITYJSTATT�tEJP <br />W <br />C-61 D-09 <br />NUMBER ' e �' DATE' 0], � �/I <br />LICENSE C-57 <br />Other -699Qf' <br />EXPIRATON <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring oil SamplinglCharacterizatio <br />Public Water System <br />If different from Owner Waler System Name Contact Name or one Number <br />TYPE OF WORK New Well Rep cement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) #of borings Geotechnical 5 # of bod gs <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />Drilling Method <iud Rota Air Rotary Eger Cable Tool Push Point Other <br />Proposed Well Depth 30 - 80 It Excavation 6 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing In diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft V Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mixl7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Metholt Pumped Free Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width It Length It Thick In Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level it 11 <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />Application Accepted By / ((/ t/V'^' Date v 1r7' i Y Area_ Employee ID# 00 0A <br />Grout Inspection By late% /_ %' %r+ SPECIAL WAII Permit <br />Pump Inspection By Date ' WAIVERReceived <br />Soil Boring ins�e;tion By _ — Date- Constructed Well Depth � ft <br />COMMENTS /K 11, 7 S�i l Lzp_ i- 1 Ix PJP to 1 `rt, <br />Codes Info V B /Cash Remitted Date Service Re uest # Invoice # Well ID# <br />y3 } I_SU /-t C �I3 t LJ 965 <br />EHD 43-08 WELL /PUMP PERMIT <br />8!04!08 <br />® r 0Q� <br />W CR oz <br />y � 9� <br />aoW <br />Lit oZ� <br />QW <br />